Case presentation of Psychotic Episode in a substance abuser

Case Presentation of Patient Yusnizam Ismail

By Nabilah Amani

BY NABILAH AMANI TOBENG

Introduction

• Name: Yusnizam Ismail• Age: 31 years old• Race:Malay• Sex: Male• Marital Status: Single• Occupation: Unemployed• Information: Incomplete and partly unreliable• Informants: Patient and case file• Rapport was established during the second

interview


Chief Complaint• Patient was brought to hospital for aggressive behavior

and assaultHistory:- On 18th September 2012, caretaker of the nursing

home noted that patient started having trouble sleeping, where he often wakes up and shout incoherently about 5- 6 times per night.

- Most of the contents were abusive language and it was unknown to whom it was directed to

- Caretaker suspected patient to have defaulted medication and returned to abusing substances such as cannabis and ecstasy for the past few days


- On the evening of 19th September 2012, patient’s behavior became more violent and he was set on assaulting others in the nursing home and surrounding community

- It was also reported in a police report attached to his case file that he carried a steel rod but no one was harmed by it as police arrived in time

- Then he was brought to the hospital by police and was admitted

- Upon questioning of the nursing home workers, his aggression was not provoked by anyone prior to his amok but he was glaring at many people as if he would attack them

- No other symptoms were noted


• On third interview with the patient;- Patient admits to have defaulted his medication

for 2 weeks prior to the psychotic episode because the side effect was disturbing him

- Details of the side effects were not clear- Claims to have met up with friends and his

brother who brought the cannabis and ecstasy for him during his stay in the nursing home. He says he hid them from everyone else.

- He remembers that he smoked a large dose of cannabis to finish them when he felt that the people in the nursing home were getting suspicious on the 18th of September, hence leading to his earlier symptoms


Past History• December 2002- First episode of drug-induced psychosis where patient

was admitted in old hospital- Patient was taking cannabis supplied by his younger

brother and friends since the age of 18 (year 1998)- He describes at the time he smoked the cannabis, he

was using a kind of wrapped leaf- Progressively, ecstasy was also included and his

cannabis dosage increased, probably being the cause for his first episode of psychosis

- In addition, his case file mentioned that he was also developed schizophrenia secondary to the substance abuse


• June 2003- Admitted into ward for relapsed schizophrenia• Patient was repeatedly admitted for either

aggressive behavior, defaulted medication, acute psychosis, relapse or mixed episodes on the following dates:

- October 2004- August 2005- June, October, and December 2006- February, June, and December 2007- November 2008- January, July and October 2010- February 2012


• Patient had been sent for drug rehabilitation multiple times

• Therapy failed to stop his addiction• Patient claims it was difficult to stop because

all his friends would often persuade him to take up cannabis again


Past Medical and Surgical History• Had a moderate velocity MVA in 2001 where

patient was thrown off his motorcycle after avoiding a lorry which made a sudden turn

• Patient was admitted into Emergency department • Injuries in his lower limbs required surgical

intervention due to open fracture on his left shin.

*Unable to elicit full history on this as patient does not remember much of the details- Apart from that, there are no other medical history


Family History


• Biological mother passed away in 2000 due to cardiac disease; patient was very attached to his mother. He was dysthymic but he denies any suicidal thoughts or feelings of worthlessness or hopelessness

• Younger brother is also a substance abuser, currently in a rehabilitation center. He has criminal records for robbery and assault

• Eldest sister and second sister live with their respective husbands in Perak

• Youngest sister (16 years old) lives with father• Family is described as disengaged, having contact with

him periodically• Unable to inquire about father as patient becomes

agitated and aggressive upon asking, probably due to unresolved childhood conflict


Personal History• Date of Birth: 17th August 1981- Claims to have been born and raised in Pahang for

6 years before family moved to Kedah when his father was transferred.

• Education: Until Form 1 (incomplete education)• Patient had poor performance in school• Marital Status: Single• Occupation: Previously was a factory worker- Has good relationship with employer whom was

understanding of his situation- Colleagues mostly avoided him and he claims they

often sneer at him for his drug abusing behavior


• Social relationships: - Most of his friends consisted of substance abusers,

hence contributes to his difficulty in stopping the habit

- He used to meet up with them on a weekly basis to smoke cannabis and ecstasy

- Has poor family support and negligent father (as claimed by patient)

• Hobbies and Interests:- Singing- Reciting poetry- Reading newspaper• Unable to elicit Psychosexual and Pre-Morbid

Histories


• Current circumstances:- Patient is being cared for in a nursing home- He also undergoes occupational therapy while

in the hospital and he claims that once he is allowed to return to the nursing home, he will go back to the factory he was previously working in

- He has no significant other to care for nor any financial responsibilities

- He only has qualms about working in the same department in the factory as he does not like his co-workers, especially those who openly mock him.


Mental State Examination• Appearance:- Normal body build and height of about 170cm- Well kempt in hospital attire- Good hygiene• Facial Expression:- Alert and responsive- Patient retains stern- looking expression• Motoric behavior:- Rigid but coordinated- Assumes “military posture” at times


• Mood:Subjective;- Bold, Confident, often assumes military-like

formalityObjective;- Mood congruent and euthymic• Affect: Appropriate• Speech:- Pressured; loud and difficult to interrupt- Spontaneous and Talkative- Normal reaction time- Partially irrelevant - Formal mannerism


Thought• Stream: - Flight of ideas and grandiosity - Quote:“Aku seorang askar, mampu berlawan dengan tangan tanpa senjata dan boleh membunuh hantu, jin, iblis dan jembalang. Kalau kau berani mengaku kau hantu, aku akan bunuh kau. Baik kau jangan cakap kau hantu….”“Mak aku mati sebelum pembedahan jantung. Doktor tak mampu buat apa-apa. Kau yang bunuh mak aku, baik mengaku!” (Points at interviewer)


Translation;“I’m a soldier, with the ability to fight without weapons and kill ghosts, jinn, demons and monsters. If you dare admit that you’re a ghost, I will kill you. Better not say you’re a ghost!”“My mother died before her heart surgery. The doctor could not do anything. You killed my mother, admit it!”• Possession: - There was no thought alienation, withdrawal,

insertion or broadcast- No obsession or pre-occupation


• Content:- Erotomanic delusions of being married to Siti Nur

Haliza (a popular Malaysian singer) since the age of 3 years.

- Consistently insists that he is married to her, even during the second interview

- Even claims that they were childhood friends when he was living in Pahang

• Perception:- Patient has no problems with perception- He denies hearing any voices talking to him, about

him or comment on his actions.- He denies having any visual hallucinations


• Cognition• Orientation:- Patient is orientated to time, place and person• Memory:- Immediate, short and long-term memories are

intact• Unable to assess attention and concentration

as he is difficult to interrupt or persuade• Unable to assess visuo-spatial organization,

calculation, abstraction or executive functioning

• Unable to assess intelligence


• Insight:- During first interview, patient has very poor

insight (may be due to psychosis)- Insight improved on second and third

interview which had a gap of 2 days each- On third interview, patient is aware of his

illness, understands that the cause is due to his poor compliance to medication and returning habit of substance abuse, and understands the impact it has to his life and his surroundings. He even says he will try to stop meeting his friends and brother in effort to break the habit.


Physical Examination*Unable to execute a full examination as it was prohibited by staff due to his unpredictable behavior and recent report of molesting a student nurseInspection:- Alert and conscious - No attachments to his limbs such as cannula, IV

drips, etc- Multiple linear scars on his face- Patient claims scars were from previous brawls Patient’s vital signs were stable and within normal

limits, the rest of the physical examination was unremarkable


Differential Diagnosis

• F20.0 – SchizophreniaDiagnosis :F12.50 – Psychotic disorder, Schizophrenia- like with use of cannabinoids


Management PlanPharmacotherapy:• If I were the attending doctor, I would administer

either Haloperidol or Diazepam IV/ IM• Once the patient is more calm, can continue with;Oral benzodiazepines, e.g. Diazepam, for anxiety

and agitationAntipsychotic medication, e.g. risperidone, or

olanzapine, or quetiapine or amisulprideSSRI or SNRI antidepressants


• Psychotherapy;• Cognitive Behavioral Therapy• Occupational Therapy


Summary

• Mr. Yusnizam Ismail, a 31 year old Malay man, was admitted in Hospital Sultan Abdul Halim for aggressive behavior, substance abuse and poor compliance. He is a known case of cannabis abuser with underlying schizophrenia since December 2002. After administration of medications, he is now in a stable phase of illness.

Documents

Case presentation of Psychotic Episode in a substance abuser